2012_0627CHECK ONE:
IRRIGATION DOMESTIC X,_____ FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE CE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The baedtilow prevention assembly detailed below has been tested ind maintained as rapmrod by TNRCC
regulations and is certified to be operating within acceptable pates.
C Reduced Pressure Principle
Double Check Valve
Manufacturer L ?Z _
Model Number _(") 0-2 vti t
Serial Number L4 () 5 ?
TYPE OF ASSEMBLY
e Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
Size
2 r/
Located At S' �� {-C. S rJ C 5 +'ea d - //C ✓� c j< x
The above is certified to be true.
Firm Name 4L-f- (r- � tt 'c Certified Tester �� �•� ,� �, a u - s
Firm Address - e 6 6,0 -1 � 1 1y,;, j ki,.r d t:rt, Tester No. 1(cx1 D 4'''--._`L Dm 19 7 j
Gable # () � ( I -L. b (P 6
Date last accu mcy tested ' l-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Cheek
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-C
C 4 ight ❑
Opened at
Opened at
--*d
F J
Tight ❑
Leaked o
_psid
d
r l
RP- id
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
,
�%
�"p�
1��
Materials
C,
vko 0 efc
Used
Test After
DC- Closed
Closed Tight C
Opened at
Opened at
,--j)sid
Repair
Tight o
� d
_psid
RP
The above is certified to be true.
Firm Name 4L-f- (r- � tt 'c Certified Tester �� �•� ,� �, a u - s
Firm Address - e 6 6,0 -1 � 1 1y,;, j ki,.r d t:rt, Tester No. 1(cx1 D 4'''--._`L Dm 19 7 j
Gable # () � ( I -L. b (P 6
Date last accu mcy tested ' l-
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy